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About 45 percent of Americans with atherosclerotic cardiovascular disease (ASCVD) experience financial hardship related to medical bills, despite most of them having health insurance, according to a new paper published in the Journal of the American College of Cardiology.

Average out-of-pocket spending per person with ASCVD eclipses $2,000 annually, almost half of which is related to medication expenses, noted lead author Javier Valero-Elizondo, MD, MPH, and colleagues.

To gather insight into how this impacts individual patients, the authors studied data from the National Health Interview Survey (NHIS) from 2013 to 2017. They focused on adults aged 18 to 64 to capture a population without universal access to health insurance, which kicks in at 65.

Overall, nearly 165,000 individuals in this age range responded to the survey during these years, 6,160 of whom self-reported having ASCVD through either coronary or cerebrovascular disease. Patients were asked questions about whether they or anyone in their family experienced any financial problems related to medical bills and were divided into three categories: no financial hardship from medical bills, financial hardship but able to pay or unable to pay bills at all.

In all, 45.1 percent of respondents with ASCVD reported some level of financial hardship related to medical bills, which would equal 3.9 million nonelderly adults when extrapolated to the entire U.S. population. About 19 percent reported being unable to pay medical bills at all, representing 1.64 million Americans.

"Our study underscores the fact that while insurance coverage is critical to protect against risk of financial burden from unexpected medical bills, current insurance structure falls short in protecting from financial hardship," senior author Khurram Nasir, MD, MPH, said in a press release. "The vast majority of individuals with ASVCD reporting problems paying bills and paying them over time are insured."

Still, insurance coverage and higher incomes were somewhat protective against financial hardship. Uninsured patients had a 1.86-fold risk of being in families facing any financial hardship and 3.27 times the odds of being unable to pay medical bills at all, while lower-income individuals were 1.34 times and 2.24 times more likely to be in those situations, respectively.

Valero-Elizondo et al. also quantified financial distress on a graded scale by evaluating how concerned respondents were about maintaining their standard of living, saving enough money for retirement and paying for normal monthly bills, housing costs, usual healthcare costs or healthcare costs for serious illnesses or accidents. Those who ranked in the top quartile were classified as having “high financial distress” and were more significantly more likely to have related problems.

“Nearly 1 in 3 ASCVD patients with financial hardship from medical bills reported either significant financial distress, cutting back on basic amenities such as food, and avoiding much needed medications,” the authors wrote. “In fact, 1 in 5 of those unable to pay medical bills at all reported all 3 consequences.

Limitations of the study include its reliance on survey data and the possibility of medical bills for conditions other than ASCVD contributing to families’ financial struggles. However, a recent study found ASCVD accounted for an average of 70 percent of families’ out-of-pocket medical spending when someone had ASCVD.